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Prepared by , Uniform Data System for Medical Rehabilitation a division of UB Foundation Activities Inc . 270 Northpointe Parkway Suite 300 Amherst New York 14228. Citation , Uniform Data System for Medical Rehabilitation 2016 The WeeFIM II Clinical Guide . Version 6 4 Buffalo UDSMR , No part of this document may be modified reproduced stored in a retrieval system transmitted. in any form or by any means electronic mechanical photocopying recording or otherwise or. used to make any derivative work such as translations and adaptations without prior written. permission from Uniform Data System for Medical Rehabilitation . This guide is for use beginning November 17 2016 It replaces all previous versions of this. guide Information in this document is subject to change without notice All information. contained in this document is accurate as of the date of publication November 17 2016 . Address inquiries regarding copyright information to . Legal Services, Uniform Data System for Medical Rehabilitation. 270 Northpointe Parkway Suite 300, Amherst NY 14228. The WeeFIM II Clinical Guide, Uniform Data System for Medical Rehabilitation November 17 2016. The Contents, Functional, Assessment Section I Introduction 1. Specialists Background 2, References 6, Acknowledgments 8. UDSMR Services 10, Sales and Client Services 10, Education and Training 10. Credentialing 10, Data Management Service 10, Consultation 11. Uniform Research Services 11, Section II Coding the Data Set 12. Data WeeFIM II Case Coding Form Instructions 13,System Case Identification 13. Case Information 13,for Medical Patient Information 15. Rehabilitation Patient Contact Information 15, Medical Information 16. Telephone, Payer Information 17,716 817 7800 Referral Information 17. Fax, Discharge Information 18,716 568 0037 Resource Utilization 19. E mail, Surgeries 19,info udsmr org Custom Information 20. Web site, Impairment Group Codes 21,www udsmr org Stroke 01 21. Brain Dysfunction 02 21,Suite 300 Neurological Disorders 03 21. 270 Northpointe Parkway Spinal Cord Dysfunction 04 22. Amherst NY 14228 Amputations 05 22, Arthritis 06 23. Pain Syndromes 07 23, Orthopaedic Conditions 08 23. Cardiac Disorders 09 23, Pulmonary Disorders 10 23. Burns 11 23, Congenital Disorders 12 24, Other Disabling Impairments 13 24. Major Multiple Trauma 14 24, Developmental Disabilities 15 25. Debility 16 25, Failure to Thrive Malnutrition 17 25. i, The WeeFIM II Clinical Guide, Uniform Data System for Medical Rehabilitation November 17 2016. The Instructions for Coding Date of Onset for Each Impairment Group 26. Functional Stroke 26, Assessment Brain Dysfunction 26. Specialists Neurological Disorders 26, Spinal Cord Dysfunction 26. Orthopaedic Conditions and Amputations 26, Major Multiple Trauma 27. Burns Arthritis and Pain Syndromes 27, Cardiac and Pulmonary Disorders 27. Developmental Disabilities 27, Cerebral Palsy 27, Spina Bifida 27. Uniform Congenital Disorders 28, Data Childhood Disorders with High Risk for Disabilities 28. Other Disabling Impairments5 28,System Program Interruptions Decision Tree 29. WeeFIM II Assessment Coding Form Instructions 30,for Medical Case Identification 30. Rehabilitation Assessment Information 30, Custom Information 34. Telephone WeeFIM II Family Centered Feedback Form Instructions 36. 716 817 7800 Case Identification 36,Fax Patient Information 36. 716 568 0037 Patient Contact Information 36,E mail Completion Information 37. info udsmr org Family Centered Feedback 37,Web site Return Contact Information 37. www udsmr org Section III The WeeFIM Instrument 38. Underlying Principles for Use of the WeeFIM Instrument 39. Suite 300 General Rating Guidelines for the WeeFIM Instrument 41. 270 Northpointe Parkway General Level Descriptions for the WeeFIM Instrument 43. Amherst NY 14228 Instructions for Using the WeeFIM II Decision Trees 44. Generic WeeFIM II Decision Tree 45, Eating 46, Grooming 49. Bathing 51, Dressing Upper Body 54, Dressing Lower Body 57. Toileting 60, Bladder Management Level of Assistance 62. Bladder Management Frequency of Accidents 65, Bowel Management Level of Assistance 68. Bowel Management Frequency of Accidents 71, Transfers Chair Wheelchair 73. Transfers Toilet 76, ii, The WeeFIM II Clinical Guide. Uniform Data System for Medical Rehabilitation November 17 2016. The Transfers Tub Shower 79, Functional Locomotion Walk Wheelchair Crawl 82. Assessment Locomotion Stairs 89, Specialists Comprehension 92. Expression 95, Social Interaction 97, Problem Solving 100. Memory 102, Appendix A Case Studies 104, Case Study Joshua Typical Development 105. Answer Key Joshua Typical Development 106, Case Study Joseph Developmental Delay 109. Uniform Answer Key Joseph Developmental Delay 110,Data Case Study Brian Traumatic Brain Injury 113. Answer Key Brian Traumatic Brain Injury 114,System Appendix B WeeFIM Normative Data 117. Appendix C WeeFIM References 123,for Medical Appendix D Glossary 127. Rehabilitation Appendix E Frequently Asked Questions 133. General Questions 134,Telephone Eating 136,716 817 7800 Grooming 137. Fax Bathing 138,716 568 0037 Dressing Upper Body 139. E mail Dressing Lower Body 140, info udsmr org Dressing Upper Body and Dressing Lower Body 142. Web site Toileting 143,www udsmr org Bladder Management 144. Bowel Management 146,Suite 300 Transfers Chair Wheelchair 147. 270 Northpointe Parkway Transfers Toilet 148,Amherst NY 14228 Transfers Tub Shower 149. Locomotion Walk Wheelchair Crawl 150, Locomotion Stairs 152. Comprehension 154, Expression 155, Social Interaction 156. Problem Solving 157, Memory 158, Appendix F Blank Coding Forms 159. Case Coding Form 160, Assessment Coding Form 162, Family Centered Feedback Form 163. Resource Utilization Form 164, Surgery Form 165, iii. The WeeFIM II Clinical Guide, Uniform Data System for Medical Rehabilitation November 17 2016. The 0 3 Form 166, Functional Appendix G The 0 3 Module 170. Assessment Domains and Items 171, Specialists Rating Scale 172. WeeFIM II Family Centered 0 3 Form Instructions 173. Instructions for Page 1 173, Instructions for Pages 2 4 174. Uniform,Data,System,for Medical,Rehabilitation,Telephone. 716 817 7800,Fax,716 568 0037,E mail,info udsmr org. Web site,www udsmr org,Suite 300,270 Northpointe Parkway. Amherst NY 14228, iv, Section I Introduction, 1, Section I Introduction. Background, The 1980s are generally thought of as the Golden Age of Rehabilitation Inpatient. rehabilitation units and hospitals were springing up everywhere Length of stay and cost did not. appear as deterrents to provision of a wide array of services Shortages of allied health. professionals cropped up all over the country as the demand grew so did their salaries Over. time however costs began to skyrocket as lengths of stay grew Suddenly rehabilitation. clinicians found themselves having to justify their services and demonstrate outcomes of medical. rehabilitation to internal stakeholders as well as third party payers and accrediting bodies There. was an increasing awareness on the part of these rehabilitation clinicians that they had no. universally accepted consistent terminology to communicate about disability although many. recognized the need its potential value and the difficulties of achieving uniformity Then in. 1984 the U S Department of Education s National Institute on Disability and Rehabilitation. Research NIDRR awarded a grant to the Department of Rehabilitation Medicine in the School. of Medicine at the State University of New York at Buffalo to develop a system to document in. a uniform fashion the severity of patient disability as well as the outcomes of medical. rehabilitation 1 A task force was charged with developing a uniform data set for adult inpatient. medical rehabilitation This task force which consisted of the codirectors of the project in. Buffalo Dr Granger and Dr Hamilton and representatives of the rehabilitation community. nationwide was sponsored by the American Congress of Rehabilitation Medicine ACRM the. American Academy of Physical Medicine and Rehabilitation AAPM R and eleven other. national organizations concerned with medical rehabilitation . The goal of the task force was to develop a functional assessment data set comprising the. minimum number of items minimal data set that would be appropriate that is one that. included only key functional attributes that were common and useful discipline free and. acceptable to clinicians administrators and researchers The task force also had to create a rating. scale to measure the items Finally the instrument had to be designed so that it could be. administered quickly and uniformly yet demonstrate validity and reliability The resulting FIM . instrument was intended to track patients from the initiation of hospital care through discharge. and follow up Periodic reassessment would measure changes in patient performance to indicate. progress toward independence primarily in personal care and mobility over time while also. providing data with which to measure rehabilitation program outcomes Competent psychosocial. skills particularly communication and cognition were recognized as important variables . The items selected for the FIM instrument were grouped as self care sphincter control . transfers locomotion communication and social cognition A four level rating scale was. originally proposed in the interests of simplicity but testing in the field led to recommendations. for greater detail In response a seven level rating scale was adopted In addition patient. demographic characteristics diagnoses impairment groups lengths of rehabilitation inpatient. stay and rehabilitation charges were included in the data set Since 1984 pilot trial and. implementation studies have been conducted to improve the clinical and technical features of the. data set especially the FIM instrument , Interest in the data set was high from the very beginning and it has continued to grow . Beginning on October 1 1987 rehabilitation facilities were given an opportunity to subscribe by. sending FIM item ratings to UDSMR and receiving summary comparison reports in return . Since then the number of participating facilities has grown to over 850 and the database now. has more than six million patient records Due to the advocacy of the medical rehabilitation field. in recognition of the utility and the standards and processes that UDSMR utilized to maintain. 2, Section I Introduction, uniformity and integrity in its database the Health Care Financing Administration HCFA now. known as the Centers for Medicare and Medicaid Services CMS approached UDSMR to. provide information that would help them develop the IRF PPS a new prospective payment. system for inpatient rehabilitation facilities In 1995 HCFA entered into a royalty free license. agreement with UDSMR to evaluate The FIM System as a possible basis for the new IRF PPS . Upon completion of its evaluation and at the strong urging of the medical rehabilitation field . HCFA selected The FIM System as the basis for its new payment system and incorporated. many of its elements including the FIM instrument into the new Inpatient Rehabilitation. Facility Patient Assessment Instrument IRF PAI , In mid 1987 just prior to the initiation of the subscriber service for the FIM instrument . pediatric clinicians and physicians in Buffalo became aware of the FIM instrument and. recognized that a pediatric version of such an assessment tool could be used to measure. functional performance in children and adolescents with genetic developmental and acquired. disabilities and in children with special health care needs Key uses of functional measures. include baseline descriptive clinical assessments for assessing severity selection of treatment. goals evaluation of treatment effects and specification of the child s and family s needs for. support In the field of pediatrics many assessment tools already in existence documented the. status of development of children however few of these instruments were suitable for. periodically tracking the progress of children toward independence in personal care mobility . and psychosocial competence , To meet this perceived need to measure outcomes of medical rehabilitation and habilitation in. pediatric populations the WeeFIM instrument was developed in 1987 by a multidisciplinary. team consisting of physicians nurses and therapists Adult FIM item definitions were modified. to accommodate the developmental aspect of child habilitation taking into account that varying. degrees of dependence are normal until the approximate age of seven years old As a direct. adaptation of the FIM instrument the WeeFIM instrument contains a minimal number of. items that measure the severity of disability Both instruments are based on the definition of. disability in the Disablement Model put forth by the World Health Organization WHO 1980 2. The WeeFIM instrument is a measure of functional abilities and the need for assistance that is. associated with levels of disability in children ages six months to seven years and older . The WeeFIM and FIM instruments were purposely kept as compatible as possible by utilizing. the same items and rating system This has served to foster a common language of disability that. facilitates communication and measurement The WeeFIM items were originally organized into. the same six sub domains as the FIM items over time however these have migrated into the. three sub domains of self care mobility and cognition As with the FIM items each WeeFIM . item is rated on a seven level ordinal scale that ranges from complete independence level 7 to. total assistance level 1 , Pilot studies conducted soon after the development of the WeeFIM instrument revealed a strong. association between WeeFIM ratings and developmental levels as reflected by the age of the. child Items on the WeeFIM instrument progress in a developmental sequence Less complex. tasks for the child such as locomotion are performed independently at younger ages more. complex tasks such as problem solving are accomplished at older ages 3 4. A WeeFIM normalization study N 450 conducted over a nine month period beginning in. late 1990 confirmed a close relationship between WeeFIM ratings and chronological age from. six months to seven years 5 The normalization study also revealed that typically developing. children beyond seven years of age tend to achieve functional independence on each WeeFIM . 3, Section I Introduction, item Although this appears to be characteristic of typically developing children the WeeFIM . instrument has wide applicability for use with children beyond the age of seven years when they. experience delays in functional development , Reliability studies of children one to seven years old with motor communicative and. neurodevelopmental disabilities and of children eight to twelve years old with cerebral palsy or. spina bifida revealed excellent test retest and inter rater reliability 6 7 Finally the equivalence. reliability of face to face assessments and telephone interviews is excellent thus facilitating the. follow up of a patient s functional status without the costly requirement of face to face. interviews 7 8, The validity of the individual WeeFIM criteria was tested using the Vineland Adaptive. Behavior Scale N 104 Batelle Developmental Inventory Screen Test N 101 and. Pediatric Inventory of Disability N 45 These studies revealed excellent robust correlation. across total scores and domain scores for children with disabilities 7 8. The validity of the WeeFIM instrument was examined through pilot studies that included. children with extreme prematurity N 149 cerebral palsy N 100 Down syndrome. N 150 congenital limb disorders N 50 spina bifida N 50 and traumatic brain injury. N 100 9 6 10 12, Studies were also undertaken at the community level to test the instrument s validity and. reliability outside the rehabilitation setting These studies included children who were receiving. early intervention services for cerebral palsy and for language and cognitive disabilities 13 14 In. addition longitudinal studies demonstrated the ability to measure functional change after. rhizotomy N 90 after cryosurgery in infants with very low birth weight and retinopathy of. prematurity N 1258 in preadolescents with spina bifida after pediatric brain tumors in. children with congenital heart disease and in young adults with dysphasia and severe. developmental disabilities 9 14 23 Additionally concurrent validity using both the WeeFIM . instrument and the FIM instrument in children eight to sixteen years old with cerebral palsy. N 20 is excellent 13, In 1994 21 415 children between five and seventeen years old were included in the National. Health Interview Survey on Disability NHISD A study conducted by Hogan et al then. applied dimensions of the WeeFIM instrument to the NHISD data to assess functional. limitations in mobility self care communication and learning ability for school age American. children 24 The study revealed mobility limitations in 1 3 self care limitations in 0 9 . communication limitations in 5 5 and learning social cognitive limitations in 10 6 Overall . 8 1 of school aged children have severe functional limitations 9 0 of children have activity. limitations and 3 5 have societal limitations WeeFIM domains account for 30 of activity. and 45 of societal limitations Thus a variety of normative clinical and longitudinal studies. involving children with disabilities demonstrate that the WeeFIM instrument is useful for. describing functional limitations By knowing a child s functional strengths and challenges . health professionals rehabilitation professionals and educational professionals can work. together to optimize development and direct family supports toward achievement of independent. adulthood , As with the FIM instrument interest in the data set was high from the beginning and continued. to grow In 1994 a pediatric subscriber service was launched Pediatric inpatient and. outpatient community based facilities were licensed to use the Uniform Data Set for Medical. Rehabilitation including the WeeFIM instrument and the accompanying WeeFIMware . 4, Section I Introduction, software to collect data for submission to UDSMR for aggregation The aggregate data was used. to prepare quarterly inpatient and outpatient reports that provided facility data and comparisons. with national data The database continued to grow over the next seven years In 2001 based. upon subscriber feedback and advances in software technology UDSMR determined that. enhancements to the WeeFIMware software and certain elements of the data set would be. appropriate Before embarking on this project UDSMR made every effort to seek input from. subscribers in order to gain a better understanding of their needs . The first attempt to canvass the subscribers involved mailing all of them lengthy surveys that. asked for opinions regarding the WeeFIM instrument itself the WeeFIMware software the. standard quarterly reports the value of the WeeFIM System the quality of services provided by. UDSMR and recommendations for the future Over 50 of the subscribers took the time to. complete the surveys and to return them to UDSMR In early 2002 UDSMR began a series of. telephone and face to face focus group meetings to learn in depth how subscribers were using. the WeeFIM System what they perceived as the major issues in pediatric inpatient and. outpatient rehabilitation and how UDSMR could better serve their needs Subscribers were. unanimous in advocating for more opportunities to network with their colleagues in. environments that focused solely on pediatric rehabilitation issues Thus in late 2002 UDSMR. made a major commitment to completely redesign the WeeFIM System At every step of the. way the redesign effort has been driven almost exclusively by subscriber feedback . The WeeFIM II System was launched in January 2004 Enhancements have been made to. almost every aspect of the system Although the eighteen items of the WeeFIM instrument. remain the same the definitions and the descriptors for many of the ratings have been clarified . The new system is Internet based thus eliminating the need to download data and send. information to UDSMR via courier each quarter It allows users to track patients across settings. via the software s inpatient and outpatient modules Other new software features include a task. scheduler and a greatly expanded software report writer which allows subscribers to create. reports based on templates provided in the software In addition a dynamic export feature allows. subscribers to select particular data elements for export to spreadsheet applications so that they. can create reports of their own design The software also contains innumerable custom fields that. subscribers can use to collect additional information for their own purposes . The impairment groups which have evolved over the years from a mirror image of the adult. FIM codes into a system more precisely tailored to the needs of a pediatric population have. now expanded from nine to fourteen groups Subscriber recommendations were taken into. account in expanding the number of groups and in adding many new subcategories . Prior to the redesign subscribers received hefty reports that they described as colorful but. difficult to interpret or share with others In response to their suggestions the redesigned reports. are more concise and contain untransformed WeeFIM ratings and accompanying graphs Three. new outpatient reports have been created These reports are based on three new admission. classes children who receive day treatment children who receive ongoing outpatient therapy. services and children who are being seen for evaluation only The updated inpatient reports. include comparisons to similar facilities as well as comparisons to facilities across the United. States , 5, Section I Introduction,References, 1 Granger CV Hamilton BB Keith RA Zielezny M Sherwin FS Advances in functional. assessment for medical rehabilitation Topics in Geriatric Rehabilitation 1986 1 3 59 74 . 2 World Health Organization World Health Assembly International Classification of. Impairments Disabilities and Handicaps A Manual of Classification Relating to the. Consequences of Disease Geneva World Health Organization 1980 . 3 Braun S Featured instrument The Functional Independence Measure for Children WeeFIM. instrument gateway to the WeeFIM System Journal of Rehabilitation Outcomes. Measurement 1998 2 4 63 8 , 4 Braun SL Granger CV A practical approach to functional assessment in pediatrics . Occupational Therapy Practice 1991 2 2 46 51 , 5 Msall ME DiGaudio K Duffy LC LaForest S Braun S Granger CV WeeFIM Normative. sample of an instrument for tracking functional independence in children Clinical. Pediatrics 1994 33 7 431 8 , 6 Msall ME DiGaudio KM Duffy LC Use of functional assessment in children with. developmental disabilities Physical Medicine and Rehabilitation Clinics of North America . 1993 4 3 517 27 , 7 Ottenbacher KJ Msall ME Lyon N Duffy LC Granger CV Braun S Interrater agreement. and stability of the Functional Independence Measure for Children WeeFIM use in. children with developmental disabilities Archives of Physical Medicine and Rehabilitation . 1997 78 12 1309 15 , 8 Ottenbacher KJ Taylor ET Msall ME et al The stability and equivalence reliability of the. Functional Independence Measure for Children WeeFIM Developmental Medicine and. Child Neurology 1996 38 10 907 16 , 9 Msall ME Functional assessment in neurodevelopmental disability In Capute AJ Accardo. PJ eds Developmental Disabilities in Infancy and Children 2nd ed Baltimore MD Paul. Brookes Publishing 1996 , 10 Ottenbacher KJ Msall ME Lyon N Duffy LC Granger CV Braun S Measuring. developmental and functional status in children with disabilities Developmental Medicine. and Child Neurology 1999 41 3 186 94 , 11 Msall ME Buck GM Rogers BT Duffy LC Mallen S Catanzaro NL Predictors of. mortality morbidity and disability in a cohort of infants 28 weeks gestation Clinical. Pediatrics 1993 32 9 521 7 , 12 Msall ME DiGaudio K Rogers BT et al The Functional Independence Measure for. Children WeeFIM Conceptual basis and pilot use in children with developmental. disabilities Clinical Pediatrics 1994 33 7 421 30 . 13 Azaula M Msall ME Buck G Tremont MR Wilczenski F Rogers BT Measuring. functional status and family support in older school aged children with cerebral palsy . comparison of three instruments Archives of Physical Medicine and Rehabilitation . 2000 81 3 307 11 , 6, Section I Introduction, 14 Gaebler Spira D Marty G Holloway D Msall M Measuring functional independence in. children with cerebral palsy following selective posterior rhizotomy Pediatric Research . 1995 37 2 378 Abstract , 15 Msall M Phelps D DiGaudio K et al Severity of neonatal retinopathy of pre maturity is. predictive of neurodevelopmental functional outcome at age 5 5 years Pediatrics . 2000 106 5 998 1005 , 16 Msall M LaForest S Buck G et al Use of the WeeFIM to facilitate functional independence. in preadolescents with spina bifida Pediatric Research 1995 37 pt 2 17A Abstract . 17 Phillip PA Ayyangar R Vanderbilt J Gaebler Spira DJ Rehabilitation outcome in children. after treatment of primary brain tumor Archives of Physical Medicine and Rehabilitation . 1994 75 1 36 9 , 18 Rogers BT Msall ME Buck GM et al Neurodevelopmental outcome of infants with. hypoplastic left heart syndrome Journal of Pediatrics 1995 126 3 496 8 . 19 Vohr BR Msall ME Neuropsychological and functional outcomes of very low birth weight. infants Seminars in Perinatology 1997 21 3 202 20 . 20 Msall ME Rogers BT Ripstein H Lyon N Wilczenski F Measurements of functional. outcomes in children with cerebral palsy Mental Retardation and Developmental. Disabilities Research Reviews 1997 3 194 203 , 21 Msall ME Bier JA LaGasse L Tremont M Lester B The vulnerable preschool child the. impact of biomedical and social risks on neurodevelopmental function Seminars in Pediatric. Neurology 1998 5 1 52 61 , 22 McAuliffe CA Wenger RE Schneider JW Gaebler Spira DJ Usefulness of the. Wee Functional Independence Measure to detect functional change in children with cerebral. palsy Pediatric Physical Therapy 1998 10 1 23 8 , 23 DeNise Annunziata D Scharf A Functional status as an important predictor of length of stay. in a pediatric rehabilitation hospital Journal of Rehabilitation Outcomes Measurement . 1998 2 2 12 21 , 24 Hogan DP Msall ME Rogers ML Avery RC Improved disability population estimates of. functional limitation among American children aged 5 17 Maternal and Child Health. Journal 1997 1 4 203 16 , 7, Section I Introduction. Acknowledgments, We begin our acknowledgements with the members of the original WeeFIM instrument. development team , Carl V Granger MD, Susan Braun MLS OTR. Kim Griswold MD MPH RN, Margaret McCabe DSN RN, Nancy Heyer RN. Michael Msall MD, Byron B Hamilton PhD MD, Naming all those who contributed to the design of the WeeFIM II System would be an. impossible task but the significant contributions of the following individuals are greatly. appreciated , Kristen Brockmeyer Stubbs MS OTR L, Patricia Bush and colleagues in the Outcomes Department of Shriners Hospital Corporation. Shirley Carlson PT MS PCS, Susan Carpenter MS MBA CCC SA. Cyndi Cortes CRNP CRRN, Karen Craig MHA, Lola Cremer PT. Melissa Crowley MA CCC SLP, Jennifer Delp, Debra J Denniger Bryant OTR L BCP. Kevin Gibson MS OTR L, Priscilla Grist CCM, Shirley Hart Riley Early Childhood Educator. Susan Hingerty MCD CCC SLP, Linda Hoffman, Cindy Iske MS OTR L. Sharon Kary Catherine Eccheveria and colleagues at the Arizona Department of Health. Barbara Ladenheim PhD, Chris Lomax, Kristin March MS OTR L. Michael Marranca BS MHA, 8, Section I Introduction. Beth McKitrick Bandy MA PT PCS, Delores A Moore, Anne Morton MA. Nina Napoli RN, Janet Padley MSEd, Marti Reese MA CCC SLP. Cynthia Salorio PhD, Steve Saunders MS CCC SLP, Laura Schroer RN BSN. Linda Silvia, Vikki Steffans MD, Cynthia Swanson SW CCM. Richard Sweitzer Ed D, Deborah Vokes OTR L, Kristin Wainscott MS CCC SLP. Kelly Wascheck, Last but certainly not least we thank the staff at UDSMR without whom there would be no.

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